CDC is on the fast track with new UTI prevention guidelines
CMS cuts drive sudden interest in the all-but-forgotten infection
The Centers for Disease Control and Prevention is drafting comprehensive new guidelines for urinary tract infections (UTIs), a complication so common and typically treatable that it has been accepted with a sort of benign neglect by the health care system.
Not any more. The so-called Rodney Dangerfield of infections is suddenly getting respect aplenty, and if you want to know why just follow the money. The Centers for Medicare & Medicaid Services' (CMS) recent decision to halt payment on additional costs generated by catheter-related UTIs and two other "preventable" infections (mediastinitis, catheter-related vascular infections) has sounded a wake-up call for hospital administrators. In addition, the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC) expects to issue new UTI prevention recommendations this summer, replacing guidelines that now are 27 years old.
The sheer totality of UTIs — the most common health care-associated infection — mean that millions of health care dollars are at stake if reimbursements are slashed as expected in new CMS regulations effective October 2008. Despite some initial protests and warnings of unintended consequences, CMS is not likely to change its perception that many UTIs are simply preventable. A recently published study by Sanjay Saint, MD, bolsters the agency's argument, as he found that that urinary catheters — a well-established risk of infection if not removed as soon as possible — are not even monitored at a large number of hospitals. In a particularly striking finding, one-third of hospitals surveyed did not conduct any type of UTI surveillance.1
With the buck stopping soon, health care facilities are looking for the most cost effective ways to prevent UTIs. That means guidelines being developed and fast-tracked by HICPAC are more likely to be a page-turner than tossed on a shelf and forgotten. "I do think these UTI guidelines will have a lot of significance," says Patrick Brennan, MD, chairman of the HICPAC committee. At recent meeting in Atlanta, HICPAC continued the process of honing down a staggering number of studies and trials into a sharply focused guideline on best prevention practices.
"As a result of new CMS requirements for reimbursement, there is a growing interest in prevention of catheter-associated urinary tract infections," HICPAC member David Pegues, MD, told HIC. "The easiest way to prevent a catheter infection is by not placing the device or getting the device as soon as possible."
Indeed, appropriate catheter placement and prompt removal when medically unnecessary are areas that will certainly be addressed in the guidelines, said Pegues, one of the principals in the UTI guideline development and director of infectious diseases at the University of California/ Los Angeles (UCLA).
"Recently, there has been an increase — although the relative number of publications remains small — in looking very critically at administrative means to decrease the frequency for which catheters are initially inserted and providing physician reminders to get catheters out sooner," he said. "Am I disappointed that physicians aren't even aware that the patient has a catheter and aren't even thinking of removing it? Certainly, but there is an answer to that [problem]. The good news is there are studies like Saint's that look at electronic reminders or administrative means to decrease the frequency of catheter use and increase the frequency for which catheters are placed for appropriate indications. We are capturing that information — including that specific study — and there will be recommendations growing out of that body of literature."
Answers not so simple
However, Brennan warned that UTIs are a complex problem, and catheter utilization is only one of the issues the committee must address. "It's seemingly simple to take the catheter out, and there certainly is a lot of utilization that is convenience-based," he said. "But there are a lot of patients where it is really hard to take the catheter out — the ICU patient, patients that are bedbound. It's tougher than it seems."
Emerging themes in the committee's review of the UTI literature include such issues as whether one type of catheterization is better than another, antibiotic prophylaxis, and use of silver- and drug-coated devices. Developing standardized approaches that could be adopted widely could go a long toward preventing an infection that strikes roughly a million patients a year.
"There is a difference between infections that are disasters one by one, like an infection after an open heart surgery — mediastinis — and infections that on a case-by-case basis aren't as overwhelming," says Michael Bell, MD, a medical epidemiologist in the CDC division of health care quality promotion who works with HICPAC. "When you look at the sheer numbers of [UTIs] they have a huge impact on health care. They are so common — so many people get them — that if you could prevent them the impact on overall health care could be pretty big. I think that is the approach that CMS is taking. It's a different type of impact and risk compared to the catastrophic individual infection."
The UTI guideline will be one of the first issued under a new HICPAC system designed to expedite the recommendations and shorten a marathon review process. Infection control professionals who waited — sometimes impatiently — for eventual release of the patient isolation guidelines last year are well aware of the problem. The most striking example is the HICPAC sterilization guideline, which has remained in draft form for five years as of February 2008. The advisory committee has long since signed off on the guideline, but it is snagged up in interagency review over issues such as conflicting federal policies and different requirements for label wording. "It's still being cleared," Bell told HIC at the meeting. "We've got the final conference call coming up."
The need for speed
Under a revamped process that includes a streamlined literature review process by HICPAC, the UTI guidelines are on track to be drafted in June 2008 and finalized in the immediate months after. "The whole guideline writing process has changed," Bell explains. "We have moved to an internal system where we do the writing with HICPAC and CDC personnel [using] a systematic way of assessing the evidence. All of that is geared toward [in part] a more rapid turn around. We are hoping for between nine months and a year for most of these guidelines. [They will] also be shorter guidelines with a clear demonstration of why recommendations are graded one way vs. another way. So that people who are reading the guideline, not only understand what to do, but how well that [recommendation] is supported."
The UTI guideline is proceeding within the new approach, with the committee using systematic published reviews rather than consulting all papers published on the topic, Brennan told HIC. "Essentially it is a trade-off between efficiency and reviewing every single paper," he says. "And when you have a yield like we did on this — 8,000 references to start with — even when you pare it down to a small fraction of that, it is still over 300 manuscripts that have to be retrieved from sometimes obscure sources and reviewed. So to be able to rely on well-done systematic reviews creates a real efficiency in the process."
Indeed, the old joke at HICPAC meetings that the guidelines would need updating by the time they are completed now has tinge of truth to it. "The biggest concern is that the landscape has changed so much over the course of the last decade," Brennan says. "We need to be much more nimble in the way that we do these. We can't afford to take years to turn these documents around anymore. In this [new] process, we are very clearly defining the questions we want to answer and then going through the grading of the evidence in a very systematic way."
Three key questions
The committee is creating the UTI guidelines around three overriding questions, which are listed below along with some of the preliminary topics that have emerged from the literature review:
- Who should and should not receive urinary catheters?
- Morbidity and mortality with catheterization
- Risk factors for UTI
- Is catheterization necessary?
- Is one type of catheterization better than another?
- Intermittent vs. indwelling catheterization
- Suprapubic vs. urethral catheterization
- Intermittent vs. suprapubic catheterization
- Clean vs. sterile intermittent catheterization
- Comparison among multiple methods
- For those who may require urinary catheters, what practices decrease the risk of infection?
- Antibiotic prophylaxis
- Bladder irrigation
- Antiseptic instillation in drainage bag
- Drainage systems/methods
- Metal care
- Silver-coated catheter
- Antibiotic-coated catheter
- Duration and/or frequency of catheterization
- Infection control/quality improvement programs
- What are the best methods to manage urinary catheter-associated complications?
- Preventing/reducing encrustations or blockage
- Catheter material
Using such questions as a focus point narrows the committee's mission and gets away from the wide, unwieldy approaches taken in the past. "It makes it possible to do this in more rapid cycle, rather than trying to address the issue of UTI prevention globally and bringing in all of the data, all of the literature and trying to sort it out," Brennan says. "At the end of the day, I don't think it's always clear what questions you are trying to answer. My personal view, having come into the process late, is that is a lot of what we struggled with at the end of the isolation guideline. We were trying to resolve open questions that hadn't been clearly defined."
- Saint S, Kowalski CP, Kaufman SR. Preventing hospital-acquired urinary tract infection in the United States: A national study. Clin Infect Dis 2008; 46:243-250.